Policy and Practice April 2017

The Magazine of the American Public Human Services

Association April 2017

WHAT IT TAKES Creating a Modern, Responsive Health and Human Services System

Plus: Old Thinking Through a New Lens The Continued Evolution of Health and Human Services

TODAY’S EXPERTISE FORTOMORROW’S SOLUTIONS

contents www.aphsa.org

Vol. 75, No. 2 April 2017

features

8

12

Joining Forces Two National

Never Get Behind Again Old Thinking Through a New Lens

Organizations Strive to Model a Generative Partnership to Accelerate Their Shared Visions

16

20

Driving Change The Continued Evolution of Health and Human Services

Improving Access, Cutting Red Tape State Lessons fromWork Support Strategies

departments

3 President’s Memo Why Framing Matters: Ways to Move Forward

26 Technology Speaks Next-Gen Child Support: Improving Outcomes for Families

5 Locally Speaking

27 Association News

Solving Complex Social Problems with Innovative Sustainable Models

Updates from NAPCWA and NASCCA

34 Staff Spotlight Jennifer Kerr, Organizational Effectiveness Consultant

6 From Our Collaborative Centers

Utilizing Our Understanding of Brain Science to Strengthen Workforce Engagement (Part I)

36 Our Do’ers Profile

Pankaj Bhanot, Director of the Hawai’i Department of Human Services

24 Legal Notes May a Foster Child Sue a Biological Parent for Sexual Abuse?

25 Wrongful Termination of Public Human Services Employees

Cover Illustration by Chris Campbell

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April 2017 Policy&Practice

APHSA Board of Directors

Chair David Stillman, Assistant Secretary, Economic Services Administration, Washington Department of Social and Health Services, Olympia, WA Vice Chair and Local Council Chair Kelly Harder, Director, Dakota County Community Services, West Saint Paul, MN Treasurer Reiko Osaki, President and Founder, Ikaso Consulting, Burlingame, CA Leadership Council Chair Roderick Bremby, Commissioner, Connecticut Department of Social Services, Hartford, CT Affiliate Chair Paul Fleissner, Director, Olmsted County Community Services, Rochester, MN Secretary Tracy Wareing Evans, President and CEO, APHSA, Washington, DC Elected Director Anne Mosle, Vice President, The Aspen Institute and Executive Director, Ascend at the Aspen Institute, Washington, DC Elected Director Mimi Corcoran, Vice President, Talent Development, New Visions for Public Schools, Harrison, NY Elected Director Susan Dreyfus, President and CEO, Alliance for Strong Families and Communities, Milwaukee, WI

Vision: Better, Healthier Lives for Children, Adults, Families, and Communities Mission: APHSA pursues excellence in health and human services by supporting state and local agencies, informing policymakers, and working with our partners to drive innovative, integrated, and efficient solutions in policy and practice.

2

Policy&Practice   April 2017

president‘s memo By Tracy Wareing Evans

Why Framing Matters: Ways to Move Forward

C hances are if you’ve read this column or heard me speak in the past couple of years, you’ve seen or heard the words “framing matters” and you know that I am a self-proclaimed “geek” of framing science and believe it is a key tool for anyone interested in moving system transformation in health and human services. In recent months, I have doubled-down on that belief, especially as we witness drasti- cally different narratives playing out across our nation. In prior issues of Policy & Practice, we have introduced you to framing and what effective framing can do to make our shared narrative more productive and impactful. We have also introduced you to experts, especially our friends at the Frameworks Institute, and the results of their research relevant to our field (see www.frameworksinstitute.org) . At APHSA, we continue to be both eager students and practicing champions of framing. We are increasingly mindful

of the pitfalls we all can fall into when describing why human services matters and what can be done to improve outcomes for children, families, and communities. In this column, I share two framing strategies that can help us avoid the most commonmistakes and produce more effective frames. Think about what happens when you add a wide-angle lens to your camera and turn to its widest position—what do you see? You capture as much of the landscape before you as possible within the frame. In the human services space, when we widen our lens, it helps us avoid the fundamental attribution error—i.e., the predominant belief that we can “fix” an individual or family through a program or service without addressing the envi- ronmental factors in their lives. In our field, too often we tell an individual First, we need to widen our lens.

success story to policymakers or the public believing that it perfectly illus- trates why a program or service works. Consider, for example, the story of a young mother who recounts the impact on her life when she is able to get a job with a meaningful wage. If the story focuses on her journey, it will likely be overwhelmed by the deeply embedded American value of hard work and grit. In other words, listeners will attribute her success to her resil- ience and fortitude alone, not also to the services around her. Too often, the story we believe we are telling simply isn’t heard. What is heard is the story of someone who overcame the odds (what Frameworks refers to as the value of “self-making”), rather than how the human-serving systems supported and empowered their journey. We have to get better at showing the full landscape. This means when we

See President’s Memo on page 30

Photo illustration by Chris Campbell

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April 2017 Policy&Practice

Vol. 75, No. 2

www.aphsa.org

Policy & Practice™ (ISSN 1942-6828) is published six times a year by the American Public Human Services Association, 1133 Nineteenth Street, NW, Suite 400, Washington, DC 20036. For subscription information, contact APHSA at (202) 682-0100 or visit the website at www.aphsa.org. Copyright © 2017. All rights reserved.This magazine may not be reproduced in whole or in part without written permission from the publisher.The viewpoints expressed in contributors’ materials are the authors’ own and do not necessarily reflect the policies or views of APHSA. Postmaster: Send address changes to Policy & Practice 1133 Nineteenth Street, NW, Suite 400, Washington, DC 20036

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Policy&Practice April 2017

locally speaking

By Justin S. Beene

Solving Complex Social Problems with Innovative Sustainable Models

Photo rendering of the first mixed-income housing complex to open in October 2017 in Grand Rapids, MI. The complex will provide permanent supportive housing to six youth who have aged out of foster care at 30% of income.

W ith a background as a recipient and provider of philanthropic efforts and human services support, I often wonder how to truly develop the economic capacity and well-being of people on the margins of society. I wrestle with some seemingly contra- dictory statistics and a puzzling trend in my own community—while Grand Rapids, Michigan, is consistently rated among the most philan-

challenging questions. A friend of mine once told me, “Once a question is raised, it must be addressed.” So I started asking these questions: “What are the frameworks and models that are innovative, sustainable, and provide dignity to people living on the margins of society? What frameworks are being implemented that work with young people who have aged out of foster care, are engaged with multiple systems, and create cross- sector solutions?” Unfortunately, the models seemed to be few and

federal Departments of Health and Human Services and Labor); through foster care contracts, Chafee Funding (for youth aging out); a Healthy Marriage and Relationship Education grant; local foundations; donations; two sustainable social enterprises, Building Bridges Professional Services and Rising Grinds Café—a landscape company and café that are funded through customer purchases—and a for-profit specialty window and door company, Double O Supply and Craftsman. Together we are addressing root-cause level needs in sustainable ways through creative multisector partnerships. Collaboratively, the partners renovated 30,000 square feet of a previously abandoned 120-year-old building in a historically disadvan- taged neighborhood. The Grand Rapids Center for Community Transformation now provides 350 youth annually with GED/high school completion courses; vocational training and certification in landscaping, construction, electrical, masonry, heating, ventilation, and air

thropic communities in the county, 1 it also con- tinues to be one of the

worst cities in the country for African Americans to live economically. 2 Despite all of the supportive efforts that have lauded national recogni-

far between; so I gathered some folks and we

started drawing up some models on our own. Today, we refer to ourselves as a movement,

tion, these alone have not proven powerful enough to drive outcomes for the African American com- munity and address systemic issues underlying poverty. Experiencing this juxtaposition has caused me to ask some deeply

the Grand Rapids Center for Community Transformation. It’s a partnership between Bethany Christian Services (funded through relationships with the local, state, and

See Locally Speaking on page 28

Images courtesy of the Grand Rapids Center for Community Transformation

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April 2017 Policy&Practice

from our collaborative centers

By Kerry Desjardins

Utilizing Our Understanding of Brain Science to Strengthen Workforce Engagement (Part I)

U sing brain science to strengthen workforce engagment and its application in human services delivery is new and largely untested. There are a few brain science-informed approaches to human services delivery and participant engagement that are delivering promising outcomes; few, however, specifically deal with employ- ability, work readiness, and other aspects of workforce engagement. Using the existing research and tools in the area, as well as employability skills frameworks, APHSA’s Center for Employment and Economic Well-Being (CEEWB) is taking a closer look at how the chronic stress of economic insecu- rity impacts people’s work readiness and employability, and how the human services, workforce development, and education systems can utilize this understanding to better serve and empower unemployed and underem- ployed workers. How Is the Brain Affected by Economic Hardship? Brain development is strongly

and improve their executive functioning skills significantly.

laymen’s terms, living under conditions of chronic scarcity and economic inse- curity often overloads people’s mental bandwidth, and reduces the cogni- tive resources they can dedicate to activities aimed at long-term decision- making and goal-achievement. The inherent stress of economic inse- curity and chronic scarcity has the

What Are Executive Skills? Executive skills—also referred to as executive functions, executive control, cognitive skills, or cogni- tive control—have been effectively described by LaDonna Pavetti as “a set off processes or skills that all have to do with managing oneself and one’s resources in order to achieve a goal.” These include: „ „ Skills we use to organize and plan things (i.e., time management and prioritization), „ „ Skills we use to control how we react to situations (i.e., response inhibition, flexibility, and emotional control), and „ „ Skills we use to get things done (i.e., task initiation, sustained attention, goal-directed persistence, stress tol- erance, and working memory).

capacity to have a negative impact on the very cognitive and behavioral skills that low-income people need to prepare for, attain, and retain

affected by the environment. Exposure to environmental risk factors such as poverty and chronic scarcity, social bias, toxic stress, trauma,

employment opportuni- ties that can lead to their self-sufficiency and sustained well-being. The good news is that growing research shows that the developed adult brain is more flexible than previously thought,

and other related risk factors directly affect the development of the prefrontal cortex and limbic system. These areas of the brain deal with execu- tive functioning such as problem-solving,

and that individuals can further develop their prefrontal cortex and limbic system

decision-making, goal-setting, goal- attainment skills, and resiliency. In

Photo illustration by Chris Campbell

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Policy&Practice April 2017

Helping Clients Strengthen Their Executive Skills and AchieveTheir Employment Goals The developed adult brain is still flexible, and it is possible for individuals to improve their executive skills. The human services system is naturally positioned to help clients exercise and improve their executive functioning skills because an important step toward achieving this is to alleviate the condi- tions that cause stress and divert brain capacity to worry instead of perfor- mance. When there is less stress, clients can focus their cognitive resources more effectively. Through its safety net programs, the human services system can support a more secure, less stressful environment. For example, enrolling clients in the Supplemental Nutrition Assistance Program (SNAP) can reduce the physical and cognitive stress of being food insecure. Helping parents to access affordable, reliable, quality child care can offer major relief from parental stress and concern about their children, which can free their cognitive resources to focus productively on their own goals.

The human services system can do evenmore to effectively serve clients to successfully prepare for, attain, and retain employment opportunities that can lead to long-term self-sufficiency and sustained well-being. The next issue of Policy & Practice will introduce readers to an executive function-informed framework for employment program and highlight a number of programs across the country that are paving the way in executive function-informed practice. Reference Notes 1. Pavetti, L. (2015). Using an Executive Function-Informed Goal Achievement Framework to Redesign Employment and Related Human Services Programs. Available at http://www. buildingbetterprograms.org/2015/07/22/ using-an-executive-function-informed- goal-achievement-framework-to-redesign- employment-programs/. 2. Office of Career, Technical, and Adult Education, U.S. Department of Education. Employability skills framework. Available at http://cte.ed.gov/employabilityskills/. Kerry Desjardins is a Policy Analyst at APHSA’s Center for Employment and EconomicWell-Being.

Executive skills are critical to nearly all aspects of life, including mental and physical health, school readiness and success, family harmony, and of course, work readiness and success. 1 Employability Skills Executive skills related to employ- ability are necessary for success in the labor market at all employment levels and in all sectors. The U.S. Department of Education’s Office of Career, Technical, and Adult Education developed the Employability Skills Framework, which divides these general skills into three broad categories: 1. Applied Knowledge— the thoughtful integration of academic knowledge and technical skills, put to practical use in the workplace. 2. Effective Relationships— the inter- personal skills and personal qualities that enable individuals to interact effectively with clients, coworkers, and supervisors. 3. Workplace Skills— the analytical and organizational skills and under-

standings that employees need to successfully performwork tasks. 2

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April 2017 Policy&Practice

“Want to go fast, go alone. Want to go far, go together” —African Proverb

Forces Two National Organizations Strive to Model a Generative Partnership to Accelerate Their Shared Visions

By Tracy Wareing Evans and Susan N. Dreyfus

T

he delivery of critical programs and services to millions of people each day illustrates the close, long-standing relationship between the public and social services sectors. Yet, the relationship is more complex than only delivery of services. Rather, it includes a shared passion to strive for a healthy and equitable society where all people can reach their full potential.

Photo Illustration by Chris Campbell

Complex challenges require adaptive solutions thatmove us innewdirections, andwe are committed

sectors, fields, and systems that we can join together in generative part- nerships, the better chance for results that will address the significant social issues facing our communities. In fact, such partnerships give the APHSA and Alliance networks a much better opportunity to create a modern and integrated health and human services system that is capable of breakthrough, generative results at the individual, family, and community levels. Generative Partnerships Are Different Generative partnerships remind us of the process of putting together a jigsaw puzzle versus playing a game of chess. These dynamic partner- ships feature unique roles, assets, and responsibilities for each sector that must be understood and respected by the other sector in order to establish a partnership that achieves true genera- tive results. APHSA and the Alliance began the journey toward a generative partner- ship more than five years ago. We started out on the right foot because while we are distinct in our sectors and our roles, as organizations we are both ultimately striving to achieve the same thing as witnessed through our organi- zational visions and missions:

But to make a truly meaningful effort to reach that goal, it is impera- tive that the sectors work within a more agile, solutions-oriented relation- ship—what we refer to as “generative partnerships.” These partnerships are more than collaborative efforts around single initiatives; their aim is some- thing bigger and their potential impact transformative. The outcomes that can be realized when the public and social services sectors work in generative partnerships are validated by a Nobel Prize-winning economist. Research by Elinor Ostrom, the 2009 Nobel Prize winner in economic science, corroborated that any complex, difficult social problem is best solved not in the public or the private sector, but rather in an environment where both sectors are working together, in earnest, to bring resolution. Cause-driven organizations like the American Public Human Services Association (APHSA) and the Alliance for Strong Families and Communities (Alliance) understand that an endorse- ment embedded in economic science isn’t enough. We know that the more

toworkingwith and through our networks and

Through these five years, our teams and members have developed rela- tionships with and learned from one another, continue to share resources, and are committed to creating new knowledge and unique opportunities for our networks. We are also very committed, where appropriate, to partner together in advocacy at the national level. Yet, we still recognize that our paths may not always be in sync and may at times require distinct journeys in pursuit of our shared visions. through generative partnerships to pave the path forward as we strive to ensure all people in our nation can reach their full potential. The experiences of APHSA and the Alliance have taught us that there are multiple benefits to be realized through generative partnerships, including: „ „ When you commit to a generative partnership, you will more fully leverage each other’s assets, expend existing resources more efficiently, and spur innovation and adaptive Benefits of Generative Partnerships

APHSA

Vision: Better, healthier lives for children, adults, families, and communities.

TracyWareing Evans is the President and CEO of the American Public Human Services Association.

Mission: APHSA pursues excellence in health and human services by supporting state and local agencies, informing policymakers, and working with our partners to drive innovative, integrated, and efficient solutions in policy and practice.

Susan N. Dreyfus is the President and CEO of the Alliance for Strong Families and Communities.

Alliance

Vision: A healthy and equitable society. Mission: To

strengthen the capacities and influence of our national network of high-impact nonprofit human-serving organizations.

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Policy&Practice April 2017

vision and principles upon which that vision will be realized, and coming together in a spirit of trust, honesty, and mutual respect. 1. Be clear on each other’s roles, dis- tinction, and boundaries. There will be times that you need to go it alone. 2. Authentic positive relationships among executive leadership and your teams are crucial and must be developed intentionally—they do not just happen. The journey to generative partnerships requires capacity development for how to engage in collective problem solving. 3. Generative partnerships happen over time. Success begets success, and you can’t rush it! 4. Generative partnerships are disruptive to status quo. At times, their untraditional nature will expose underlying tensions and leaders must be able to fully hear those concerns while keeping focused on solutions. 5. Each partner must articulate early and clearly a shared vision and core beliefs, as well as each organization’s commitment to advancing individually and in your collective work. 6. You can’t put a price tag on honesty, transparency, trust, and respect as the foundation for generative partnerships. Generative Partnerships and Networks Key As the generative partnership between APHSA and the Alliance con- tinues to evolve, we believe we will be modeling for our field and sectors one of the keys necessary at the local, state, and national levels to achieving a more modern and integrated health and human services system capable of breakthroughs and durable results. The road before us as leaders is exciting, challenging, and full of opportunity and uncertainty. Complex challenges require adaptive solutions that move us in new directions, and we are committed to working with and through our networks and through generative partnerships to pave the path forward as we strive to ensure all people in our nation can reach their full potential.

solutions, which actually generate new resources. „ „ You gain “co-owners” rather than “renters” of your shared cause. Generative partnerships last beyond individual leaders and have the capacity for achieving population- level results. „ „ You gain access to additional per- spectives and insights necessary to help all of us understand root causes of the nation’s tough societal issues, and systemically address the causes of stressors facing families and communities. „ „ When times get tough, these are the partners who are by your side to help keep you focused on the “north star.” „ „ Sustainable systems change becomes more attainable. When two distinct systems partners come together, the capacity and leader- ship to create longer-term change are more achievable.

These benefits are not unique to our partnership. They are easily trans- ferred to any set of cross-sector leaders who fully understands that we need adaptive solutions to adaptive chal- lenges, and that the old “technical solutions” are no longer viable in the 21st century. Accelerants to Generative Partnerships As we reflect on the last five years and look forward to the future on our continued journey to generative work, we have come to understand through experience that there are six accelerants that are core to creating, developing, and sustaining generative partnerships. We believe these are highly trans- ferable to all partnerships that are striving to realize breakthrough results. However, none are more important than sharing a common

The Alliance and APHSA partnership journey can be viewed through the lens of the Human Services Value Curve . At the regulative stage—i.e., ensuring integrity in our products and services—our back of ce teams have shared their approaches and experiences for effective delivery on member services, including databases, websites, and other key platforms. At the collaborative stage, we've partnered on speci c projects and presented at each other’s events, lending the joint voice of public and social serving sectors to the eld. As we've developed our partnership, we have also focused on our shared values and mapped the ways in which our respective tools and frames are in sync. This collaborative work has allowed us to get underneath a number of the surface issues and begin to understand how our sectors can partner in ways that address root causes and collectively impact outcomes for children and families—the integrative stage. As we explore these connections more deeply and through the lens of overall population health and well- being of the nation, and at state, local, and community levels, we see the potential for a meaningful, durable generative partnership.

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April 2017 Policy&Practice

Never Get Behind Again: Old Thinking Through A New Lens

By Leo Ribas, Wayne Salter, and Blake Shaw

A

lways falling behind? Do the long lines, full lobbies, and never-ending

stream of new work ever stress you out? Do you feel yourself aging at the very mention of the word “backlog”? You’re not alone. The Great Recession of 2008 forced nationwide budget cuts leaving us with 30 percent less staff just before the Affordable Care Act increased our workload by 150 percent. These events created a perfect storm in our human services agencies that we have been trying to weather ever since.

Illustration via Shutterstock

There have been many attempts to deal with the aftermath, including sophisticated IT systems, call centers, interactive voice response systems, online applications, automated work flow, and automated pending notices. While designed to help us manage the tidal wave of work and meet the needs of our customers, we ended up with systems that manage our work in the 20–45 day range instead of looking at innovative ways to do much more with less. In other words, our efforts focused on coping with the debris left by the storm, not dealing with our new reality; the storm is the new normal. The number of customers coming in is not slowing, the complexity of the work continues to grow, and the pressure to meet our deadlines is all- consuming. Amplifying our problem is the fact that every technology solution we put in place and every mandatory

guideline change requires training that pulls staff away from customers. Our hope is that with these changes we can keep up but the truth is we are only seeing longer transaction times, rising costs, and growing backlogs. There’s a secret to living peace- fully in the storm. Step 1 is to realize that much of what is being tried is not helping, and is most likely hurting us. Step 2 is to change our focus from 30-day timeliness to one-day timeliness. This may sound too simplistic but the “best practices” to weather the storm today deal with moving lines faster upfront and freeing up caseworker time behind the scenes to concentrate on doing the work. This effort to “protect” the caseworker means allotting time away from clients to work uninter- rupted and free of distractions to catch up on cases. In theory this designated time to do the work should help, but while we can isolate the worker, nothing can or should stop the clients from trying to interact with us. It’s as if only one team takes a timeout to strat- egize but the other team keeps playing. When a customer cannot access their caseworker, they begin working dif- ferent avenues to get information. They call, or “pop in” to the office, or even resubmit a new form in an attempt to see progress. Data show that after just one week, you can expect the average client to make four to five additional interactions for a single eligibility event. While we can empathize with the customer’s frustration, we often fail to see the self- inflicted damage done when we remove caseworkers from clients. Each additional contact requires us to complete 10 to 15 minutes of work, a “pendalty” for pending cases that adds up very quickly. We are literally adding hours of time for every client we “pend” and days and weeks to the time to reach a determination. For every 100 clients that walk in the door, an average of 60-plus will be pended in states and counties that have not shifted to first- contact resolution. Those 60 average four additional contacts of 15 minutes each for a total of 60 pendalty hours of work for every 100 clients. That’s one and a half full-time caseworkers just to keep up with the pendalty time.

Key Term

pend-al-ty (noun)

When these pendalty minutes catch up to us and we cannot keep up, we implement overtime for our staff. While this helps the agency maintain timely performance, the problem is that overtime becomes the normal, not the exception. Overtime should be reserved for times when it is truly needed, such as peak enrollment times. When it is the new normal, workers are losing their work–home balance, we are spending more and more money, and spending more time managing schedules than thinking about the root causes of the problem: We can’t keep up. In search of a more permanent solution, we turn to technology. However, many of us have spent millions of dollars on new systems that give clients access to data about their status in the hope that they would stop calling, popping in, and resubmit- ting, but that does not connect us to the client in a way that helps us make determinations or increase caseworker capacity. The truth is, unless it can speed up the time to disposition, it’s 3. the number one contributor todelays in gettingour clients the answers they need 1. a name for the additional work added to each determinationdecision that is pended 2. a punishment imposed for not inishing thework during the initial contact

Leo Ribas is a Consulting Partner at the Change and Innovation Agency.

Wayne Salter is the Associate Commissioner for Access and

Eligibility Services at the Texas Health and Human Services Commission.

Blake Shaw is a Senior Partner at the Change and Innovation Agency.

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Policy&Practice April 2017

Increasing Capacity Sum of Two Elements:

1 faster determinations • first contact resolution eliminates unnecessary customer interactions • fewer customer interactions frees up staff time • freed-up staff time fuels agency’s ability to reduce cycle times

=

Faster Dispositions

Capacity to Process More Work

less churn • fewer denials/terminations due to missing interviews or failure to provide verifications reduce unnecessary rework (re-opens)

2

Instead of protecting caseworkers , connect that caseworker to the customer as soon as possible, and allow them to address as much of the customer’s needs at the time of the first interaction. Even if this drives up interaction time, it is essential that we do everything we can to try to make a determination on day one. If the key to unlocking your staff capacity is to eliminate the reasons that keep bringing customers into your lobbies and phone centers, then set up your processes, your technology, and your entire work areas to focus on first contact resolution. Instead of managing overtime, we need to measure real-time customer demand more clearly and then manage day one workforce availability and staff utilization to match. Lobby and nonlobby traffic ebb and flow but we rarely move staff focus to assure work keeps moving. What we end up with is high pends in certain areas where we could have adjusted staff levels on day one to increase resolution and minimize the pendalty we now have to pay. By managing our staff in real time, we are able to provide faster transaction times, reduce pends and pendalty, and keep up with the majority of the work coming in. Oh yeah, it’s also a lot cheaper.

Instead of technology,

not going to calm the storm or save us from the additional contacts. The contacts have become so pro- nounced that we have built phone centers dedicated to diverting calls from the caseworker but even these require an agent to create a task or message that eventually requires case- worker action. The distraction wasn’t eliminated, simply delayed. All these strategies assure we stay in the storm by either encouraging the act of pending, or are a direct result of those pends. We are literally spending hundreds of millions of dollars trying to manage pended work instead of focusing on the second secret, focus on day one. By focusing on day one, the first customer interaction, we can weather the storm by doing everything within our power to complete the transaction and avoid as many pends (and pendalty minutes) as possible. We need to do this, even at the expense of getting through the line faster. By slowing down and completing the transaction (no matter fromwhich access point), we actually speed up the entire process. By how much? Just taking an additional 15 minutes to resolve a case on day one is the equivalent to adding a full-time staff for every 100 clients you serve. Instead of spending resources on pendalty, you are actually freeing up time and building capacity!

focus on the needs of the customer. What do we need to do today in order to make this determination? Are there people we could contact now, together, who can provide us with the information we need? If we absolutely have to pend, and there are some cases where we do, then let’s use the technology to provide our customers with reliable information so they don’t feel like they have to contact us unnecessarily. Instead of just informational phone centers, turn your call centers into extensions of your lobby and provide full service to those calling in. Empower them to complete transactions and work on pulling cases from the queue. If we can do a good job at day one, pendalty calls about “where’s my stuff” and status will dramatically fall within the first quarter and your call centers will have capacity to attack the backlog. There is a secret to never getting behind again. We need to shift our focus from just keeping our heads above water, understanding that, in reality, those efforts are only tiring us out and cannot be sustained. To find

&Innovation Change

agency radically improve performance

See New Lens on page 35

15

April 2017   Policy&Practice

Driving

Change The Continued Evolution of Health and Human Services

By Doug Howard

D

iscussions about creating modern and responsive health and human services are not new conversations but they come at a critical time. There

are significant federal policy considerations in play, new governance models are emerging, and technology continues to advance at an increasingly rapid pace. Engaging in the discussions is a start, but action must be taken for it to matter. As a leader, driving system change can invite critics, raise operational challenges, and feel risky and uncomfortable, but in the long run it isn’t about comfort, it’s about better outcomes.

Photo illustration by Chris Campbell

The following section is a frame- work checklist I have used in both managing business as usual and in driving change. All of these elements are critical in changing the way we do business. Framework Checklist Define a Clear Vision. Have a clear vision for success; periodic bench- marks against the vision can create momentum and a sense of achieve- ment. Some benchmarks may be process oriented but should tie to the long-term vision. Define Success. Don’t start if you didn’t define it. Lack of clear success measures inhibits motivation and can send people on different paths. Return on Investment (ROI). You must show that the change or initia- tive is a good investment of public funds. You need a clear case on what the investment is, how the investment improves outcomes, and a defensible way to measure the return for your funders and the general public. It’s not just math, you must frame up and articulate a compelling case. Sustainability. Think about sus- tainability up front, during, and after. Having a plan makes for an easier sell, but sometimes you have to move ahead without one, knowing that if you drive the right outcomes and show a significant ROI, you will find a way to sustain it. Create a Clear Governance Structure and Accountability. Define decision-makers, stakeholders, influencers, funders, and service operators and what is expected of everyone. Recognize the voice of the customer. Check your governance against the Human Services Value

Performance Orientation. Think through how to imbed a performance orientation into service delivery via measurements, contract vehicles, and other design elements. Performance- based contracting has grown in use as a vehicle to share risk, provide incen- tives to encourage innovation, and drive better outcomes. Data and Analytics. Good data and measurements have three char- acteristics or a path to get there: they are meaningful, memorable, and actionable. Determine the need for and value of program and process analytics, predictive analytics, and behavioral analytics. Determine if you have to acquire the capacity for these where they do not exist, and how you develop a baseline to measure against in future years. Technology and Tools. Determine how you can leverage existing tech- nologies and tools, and be aware of new technologies and tools that have emerged. Differentiate between what is critical and what is nice to have. Determine whether there is an opportunity to leverage a partner’s technology. Changing the Way We Do Business Social determinants of health, brain sciences, the Human Services Value Curve, family-focused initiatives, and behavioral and predictive analytics are not new topics. However, recent research, development of evidence- based practices, better tools and technologies, and increased inno- vation have raised their profile in driving change. Brain Sciences. Research shows that brain development at a young age

Curve (see the February 2017 issue of Policy and Practice for an in-depth article on this topic). Develop Leadership. It’s easy to rely on the usual leaders. Remember that leaders come from all levels, don’t have to be managers, and don’t have to have years of experience. Creating nontraditional leaders as part of the solution can be both motivational and developmental (bonus earned for suc- cession planning). Change Management and Communication. New models are exciting to some and scary to others. Convey a clear set of expectations and provide supports and opportunities to help staff, program participants, and other key stakeholders understand and accept what the changes are and why. Be open to their feedback, look for actionable input, and be prepared for attrition by those who can’t adapt. Policy Impacts. Consider how dramatic shifts in policy might affect the plan and vision. Look for oppor- tunities to pursue policy goals via evidence-based practices and always look for both opportunities and unin- tended consequences for cross- and inter-program impacts. Service Delivery. It’s easy to defer how services will be delivered but it’s not a good idea. Planning should include testing, pilots, implementa- tion, and contingency plans. Think about in-house capacity and compe- tencies and whether to procure for capacity and competencies, noting that procurement may also allow redi- rection of existing resources to other mission-critical areas. Look for ways to encourage service delivery innova- tion; I define innovation three ways: new things, improving on old things to drive better results, and using old things for a new purpose.

Doug Howard is the Senior Vice President, Human Services North America, at MAXIMUS.

See Driving Change on page 31

18

Policy&Practice April 2017

Improving Access, Cutting Red Tape

By Elizabeth Lower-Basch

State Lessons from Work Support Strategies

A

ccess to key benefit programs, like health insurance (Medicaid), nutrition assistance (the Supplemental Nutrition Assistance Program, or SNAP) and child care assistance (the Child Care and Development Block Grant, or CCDBG), reduces poverty, 1 supports

stability and success at work, 2 helps people meet basic needs, 3 and improves low-income children’s long-term health and economic well-being. 4 But despite the large and growing body of research demonstrating these successful outcomes, disadvantaged families frequently do not receive and keep the full package of benefits for which they are eligible. As many as a quarter of families eligible for both Medicaid and SNAP miss out on one or both. When capped programs such as child care or housing are considered, the partici- pation rates are much lower. 5

Illustration via Shutterstock

Services, Christian Soura explained that same-day service avoided the need to schedule and reschedule inter- view appointments. States were able to make these major improvements while continuing to maintain program integrity. Some states had initially worried that attempts to speed benefit processing would result in increased errors, while others believed use of electronic verifications would reduce mistakes. The final evaluation report reviewed the data on SNAP error rates and concluded there was no consistent rela- tionship between payment accuracy and improvements in timeliness. 2. Under the existing federal–state structure, states had the power to make the key policy changes 7 needed to achieve these outcomes. When they set out to integrate policy across programs and make service more family centered, state leaders were often surprised to learn that many problematic policies were the result of state choices, not federal requirements. As one state official dis- covered, “The more we study the steps in the application process, the more we learn that we have promulgated rules that are not mandated.” Many states learned that they were relying on paper verifications when electronic sources were available, or collecting verifications not needed by federal law. Every piece of paper a customer submits must be processed by a caseworker, so streamlining verification policies can both improve “That means making smart investments in technology and integrating services not only to reduce the costs to taxpayers but more importantly to help people find the jobs

Recent evidence illustrates how several states achieved large-scale improvement in families’ access to the full package of programs, using opportunities that exist today under Medicaid, SNAP, and the CCDBG. This evidence comes from a rich series of evaluation and technical assis- tance reports from the Work Support Strategies (WSS) initiative, a founda- tion-funded initiative led by the Center for Law and Social Policy (CLASP) and its national partners, the Center on Budget and Policy Priorities and the Urban Institute. The WSS provided funding, peer learning, and expert technical assistance from 2011 to 2016 to six diverse states (Colorado, Idaho, Illinois, North Carolina, Rhode Island, and South Carolina) to design, test, and implement more effective, stream- lined, and integrated approaches to delivering key supports for low-income working families with two goals: ensuring that all families get and keep the full package of benefits for which they are eligible and reducing the burden of bureaucratic processes. Among the problems states targeted— which burdened both families and state workers—were overly complex policies and procedures, inadequate computer systems, and bureaucratic hassles such as confusing notices, long waits to meet with a caseworker, or duplicative verification requirements. As Idaho Governor C.L. “Butch” Otter explains, “Idaho is committed to helping families find paths out of poverty and into the workforce. That means making smart invest- ments in technology and integrating services not only to reduce the costs to taxpayers but more importantly to help people find the jobs they need to support themselves and their families.

Key Publications from the Work Support Strategies Initiative

12 Lessons on Program Integration

Improving the Efficiency of Benefit Delivery

Changing Policies to Streamline Access to Medicaid, SNAP, and Child Care Assistance Improving Business Processes for Delivery ofWork Supports for Low- Income Families

Observations of Leaders Driving Change in State Government

Changes in Joint Medicaid/CHIP & SNAP Participation Rates, 2011–2013

More resources available at http://www.clasp.org/wss

This effort is aimed at increasing self- reliance and enabling success, not fostering entitlement and government dependence.” In reviewing the final evalua- tion, implementation, and technical assistance reports, we find five major lessons: 1. Significant improvements in key outcomes, including participa- tion in the full package of benefits without loss of accuracy. Other accomplishments included much faster delivery of benefits (some states doubled and tripled same-day services) and in some cases, reduced “churn,” or cycling on and off benefits. 6 Receiving benefits faster is crucial for families who frequently experienced hardships such as housing loss or food insecurity while waiting for a benefit determination. Several of the WSS states set same-day service as a goal. In addition to the improved customer experience, states reported that this saved staff time and state resources by elimi- nating unnecessary interactions. For example, South Carolina Director of the Department of Health and Human

Elizabeth Lower- Basch is the Director of Income andWork Supports at the Center for Law and Social Policy (CLASP).

they need to support themselves and their families.”

C.L. “BUTCH” OTTER, IDAHO GOVERNOR

Policy&Practice April 2017 22

broad enough to apply across agencies, programs, and priorities. For example, North Carolina’s vision was that “families will tell their stories once and receive the services they need.” At the same time, states highlighted the importance of flexibility on the ways to achieve these goals. States committed to a culture of experi- mentation and use of data to provide feedback on what was working. As states listened to multiple stake- holders and identified problems, they piloted solutions at a small scale, allowing them to test their hypoth- eses. Sometimes this resulted in quick wins—and other times it allowed states to “fail quickly, and learn quickly.” This nimbleness, commit- ment to taking risks, and humility to learn proved invaluable. Data, a key part of this process, allow states to measure progress toward goals. However, participants high- lighted the importance of defining the questions first and then building the data around those questions, rather than allowing the data to define the questions. Front-line staff and supervi- sors often needed training in order to become effective consumers of data, not just collectors. States also used caseworker perception or quick client surveys to assess their progress before formal evaluation data were available. 4. To achieve the goals, states had to change many aspects of their delivery systems at once—business process, technology, data, policy, leadership, and management struc- tures. The WSS states upgraded their business processes, such as improving customer greetings and addressing workflow inefficiencies. Several states trained workers to process applica- tions for multiple programs. States also made significant policy changes. There was no silver bullet, and every change had ripple effects in other areas of the project. States highlighted the importance of thinking through business processes and knowing how technology would be used before delving into systems change, rather than expecting a new system to solve all their problems. States recommended taking the time

Medicaid eligibility using information customers already provided for SNAP. South Carolina used the express-lane eligibility option to maintain Medicaid health coverage for more than 140,000 children without the need for families to complete any Medicaid paperwork. Illinois used a waiver to enroll 40,000 nonelderly, nondisabled individuals in Medicaid based on SNAP receipt. 3. States needed a clear vision for where to go, as well as openness to learning the best ways to get there. Leaders across states widely cited the value of developing a concrete vision that catalyzed support among internal and external stakeholders and was specific enough to operationalize, yet

the customer experience and increase efficiency. For example, Rhode Island administrators learned their require- ment for child care applicants to submit detailed work schedules caused major delays, especially for customers with fluctuating schedules. By elimi- nating this requirement, Rhode Island dramatically increased its timeliness in processing applications. In these cases, the primary federal role was simply to reassure states that, indeed, they had the authority to make the changes they desired. In other cases, states took advan- tage of options or waivers allowed under federal law. One significant example is the opportunity to verify

See Red Tape on page 29

April 2017 Policy&Practice 23